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Based on review of facility policy, personnel files (PF), and interview with facility staff (EMP) it was determined the facility failed to ensure a current licensure was provided by one of 17 personnel files reviewed, which resulted in a registered nurse working 5 months without a current license before it was discovered. (PF1, PF2, PF3, PF4, PF5, PF6, PF7, PF8, PF9, PF10, PF11, PF12, PF13, PF14, PF15, PF16, and PF17).


Review on October 5, 2016 of the facility policy,"Employee License" dated last reviewed September 5, 2015 revealed, "employee Licenses For positions which require Pennsylvania license (registered nurse, etc.), the Human Resources Department will, at the time of hire, verify the credentials of the employee. This verification process will occur on an annual basis for current employees in positions requiring state licensure. It shall be the responsibility of the Human Resources Department and/or the Department manager to assure that copies of current permits, licenses, certifications, etc. are in the employees' personnel files for those employees in a job category specifically requiring licensure or certification from the Commonwealth of Pennsylvania."

1. Review on October 5, 2016, of PF1 revealed no current license within the file. When a current license was requested from the facility, it was revealed that PF1 license expiration date was April 30, 2016. This was not discovered by EMP 2 until September 26, 2016. The State Board reinstated the license for PF17 on September 30, 2016. PF17 did not have a current license from April 30, 2016, until September 30, 2016.

2. Interview with EMP 2 on October 4, 2016 confirmed that PF17 did not have a current license from April 30, 2016, until September 30, 2016. EMP 2 further confirmed that this was not discovered until September 26, 2016. EMP 2 confirmed that the policy for employee license was not followed.

Based on review of facility documents, credential files (CF), and staff interview (EMP), it was determined the facility failed to ensure privileges were granted in accordance with established guidelines for two of 23 credential files reviewed. (CF1, CF2, CF3, CF4, CF5, CF6, CF7, CF8, CF9, CF10, CF11, CF12, CF13, CF14, CF15, CF16, CF17, CF18, CF19, CF20, CF21, CF22, CF23)

Findings include:

Review on October 4, 2016, of the facility policy, "Bylaws of the Medical Staff of Wayne Memorial Hospital," last revised April 1, 2015, revealed, "Article I: Preamble Definitions Whereas, Wayne Memorial Hospital is a non profit corporation organized under the laws of the Commonwealth of Pennsylvania with the purpose of maintaining a licensed hospital providing inpatient and outpatient care, education and research to meet the health care needs of Wayne County and surrounding communities; and Whereas, the Hospital's Board wishes to delegate to the Medical Staff., and specifically to certain officers of the Medical Staff, duties and responsibilities for monitoring the quality of medical care in the Hospital and reporting thereon to the Board and the authority and responsibility to make recommendations to the Board concerning an applicant's appointment or reappointment to the Medical Staff and the clinical privileges such applicant shall enjoy in the Hospital; Therefore, to discharge these duties and responsibilities to the Hospital in an orderly fashion the physicians, dentists and podiatrists practicing in Wayne Memorial Hospital shall function and act in accordance with the following Bylaws, Rules and Regulations and policies and procedures which have been approved by the Board. The Hospital management shall cooperate with and assist the appointees to the Medical Staff in the accomplishment of these responsibilities to the Hospital. ...10.02 Temporary Clinical Privileges Temporary clinical privileges may be granted for a limited period of time in two situations: (1) to fulfill an important patient care, treatment and service need; and (2) when a new applicant with a complete, clean application that raises no concerns is awaiting review and approval of the MEC and the Board. 10.01.1. Temporary Clinical Privileges for Applicants-Temporary clinical privileges for new applicants may be granted for a period of not more than 120 days while awaiting review and approval by the MEC and the Board upon verification of the following: (a) current licensure; (b) relevant training or experience; (c) current competence; (d) ability to perform the privileges requested; (e) other criteria required by the Bylaws; (f) a query and evaluation of the NFDB information; (g) a complete application; (h) no current or previously successful challenges to licensure or registration; (i) the applicant has never been subject to involuntary termination of medical staff membership at another organization; and (j) the applicant has never been subject to involuntary limitation, reduction, denial, or loss of clinical privileges. ...
Article IX Reappointment 9.01.1 Reappointment application-A current appointee who wishes to be reappointed shall be responsible for reviewing his initial application form and notifying the credentials committee of any material changes in his information given there, particularly with regard to any professional competence or disciplinary action taking or pending against him in another hospital or healthcare facility and any changes in the status, amount or coverage of his professional liability insurance coverage, as well as any change in his state license to practice medicine, dentistry or podiatry and shall, upon request, submit proof of such current state license or insurance coverage. An appointment application form shall be completed by the applicant prior to reappointment. Failure to provide information pertaining to an individual's qualifications for reappointment or clinical privileges, in response to a written request from the credentials committee, the MEC, the chief executive officer, or any other committee authorized to request such information, shall result in the automatic relinquishment of clinical privileges until the information is provided."

1. Review on October 4, 2016, of CF1 revealed a gap letter with temporary privileges was sent on August 31, 2015 to CF1.

2. Interview on October 4, 2016, at approximately 1100 with EMP20 confirmed a gap letter was sent on August 31, 2015, with temporary privileges. EMP20 confirmed temporary privileges may only be granted for a period of 120 days while awaiting review.

3. Review on October 4, 2016, of CF8 revealed the reappointment application was not completed. The credentialing period of 12/5/2015 to 12/05/2017 was approved without the completion of the form. It was confirmed by EMP2 that CF8 had relinquished privileges at another facility in April and in August an updated data bank revealed action had been taken against CF8's license. This was discovered when the updated data bank was sent to the facility in August confirming a suit pending. At that time CF8 informed EMP2 he had relinquished privileges at another facility. The reappointment form asks the following question,"Have any professional liability suits been filed against you since the last appointment? and Since your last appointment, have you voluntarily or involuntarily relinquished your privileges or medical staff membership at another facility?" EMP 2 had no explanation as to why credentials were approved without this section being completed by CF8.

4. Interview with EMP2 on October 4, 2016, confirmed that the credentialing process was not followed. EMP 2 further confirmed that this was just discovered and as a result privileges for CF8 were approved on October 3, 2016, as temporary for courtesy staff.

Based on review of facility policy and documents, and interview with staff (EMP), it was determined the facility failed to ensure that established nursing policy for daily code cart check was implemented 41 times in a three month period.

Findings include:

Review on October 6, 2016 of the facility policy, " code-carts-checking" dated revised March 9, 2016, revealed,"Procedure A.. Code Carts are inspected daily by department personnel for lock integrity in departments that are open 24 hours. All other department code carts are inspected daily by department personnel when the department is open. " B. Inspection of crash cart is documented on the Crash Code Check form."

1. Inspection on October 4, 2016, of the daily code/crash cart check on the 4th floor medical surgical unit for the months of July, August and September of 2016, revealed that the crash cart was not checked 19 times in July, nine times in August and 13 times in September.

2. Interview with EMP15 on October 5, 2016, confirmed the crash cart was not checked daily and the policy for code cart checks was not followed.